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THERE has been significant media coverage regarding the legislative changes on MBS/PBS subsidies for nurse practitioners (NPs).
Reports abound of physician groups refusing to accept patient referrals from NPs, fears of a sharp rise in acute renal failure due to nurses inadvertently exposing their patients to the “triple whammy” of ACE-inhibitors, diuretics and NSAIDs, and the general collapse of the health care system due to the sudden influx of prescriptions that will be written by NPs for their clients.
At the risk of sounding cavalier, it feels a bit like Chicken Little, really.
These claims are made despite the overwhelming evidence demonstrating a 10-year history of safe, efficacious, and cost-effective care provided by NPs here in Australia and worldwide since the 1960s.
I find all this unusual because I trained as an NP alongside medical colleagues in the United States.
There was true collegiality and respect for the perspectives that the nursing and medical models afforded.
We worked in collaboration, offering complementary health care that brought about the best possible outcomes for our clients.
I acknowledge that the US health care system is far from perfect, but at the end of the day patient care still remains much the same as in Australia.
I believe that the medical model does not offer the complete answer to an effective health care system — and neither does the nursing model.
Neither model operates to its full capacity without collaboration with and facilitation by the other.
So why are we, as collaborating health care professionals, engaging in shock and fear media reports, which do nothing but instil public distrust in the health care system?
Instead of engaging in these arguments that accomplish nothing apart from wasting time and money, why don’t we truly collaborate and encourage each other’s professional aspirations, talents and abilities?
Is there a perception that nurses can’t possibly have the training, experience or intelligence to safely manage a patient with heart failure or other complex illness?
NPs in Australia have advanced training at the Masters level with an emphasis on pharmacotherapeutics, diagnostics, differential diagnosis and advanced physiology.
Many of us have trained alongside or taken the same courses as our medical colleagues.
We have been accredited by a national body using standards that are rigorous and discerning.
We have years of practical experience working with clients within our respective specialties and have done so efficiently, safely and effectively without the pharmacological or diagnostic tools that have traditionally been used by the medical profession.
Allowing NPs to access the MBS and PBS aids in the progression and evolution of the nursing profession, validates the delivery of quality NP patient care, provides for improved health care access and accommodates patient choice.
This natural professional evolution cannot occur without the support of our medical colleagues.
Likewise, the medical profession could not have evolved without the support of their nursing colleagues through their training and care delivery to patients, families and communities.
This is our opportunity to strengthen our partnerships using innovative health care delivery teams in an attempt to provide one of the solutions for this country’s ailing health care system.
My physician mentor once said to me: “Chris, you must have the courage of your convictions.”
I invite you to have the courage to join the many nurses and physicians who have decided to stand in support of the NP profession and explore how this role may benefit your practice and clientele.
Mr Chris Helms is vice-president of the Australian College of Nurse Practitioners.
Posted 22 November 2010
Getting slightly off the track – I have noticed with the advent of specialist nurses, not necessarily NPs, the decline in overall knowledge of registered nurses at ward level. Referrals to the specialist nurse seems to imply the ward nurse has no need to maintain skills and knowledge. This is all very well except for after hours and weekends when there is no-one to call. Resident MOs expect the reg nurse to be able to recognise and treat events such as “hypos”. I recommend putting more resources into the training of the reg nurse on the ward and ensuring their work is appropraitely valued.
The real problem is that nursing has neither progressed nor evolved as a profession, it has abandoned its very foundations. Until the middle of the last century attentive and devoted nursing care was the reason for the survival of many if not most patients. With the explosion of new surgical, anaesthetic and therapeutic techniques nurses began to lose their way and forget that sick patients still need to be nursed. As a result many medicos and nurses now dread the thought of becoming really sick as their chance of being nursed is minimal. As the recipient of life saving open heart surgery recently I was appalled at the lack of real nursing. In ICU tests were done, injections given, drugs administered but never was I washed let alone have my back rubbed. No wonder that patients still develop bed sores. Then I went to the ward and the “nursing model” of self care, which was really one of not so benign neglect.
Please let both professions evolve in parallel to do both what we should do best, nurses nurse and doctors practise medicine.
In my view, there are two ways of looking at the role and place of NPs in our healthcare system. On the one hand, you could step back and say that, so long as they take responsibility for their own decision-making and outcomes, anyone can do whatever they like (with the appropriate training and registration – of course). That would be the “let the market decide” approach. On the other hand, you could argue that public money shouldbe used in a cost-effective way. Any particular practitioner, who is publicly funded through either salary or Medicare, needs to show that their service is useful and reasonably cost-effective. If the NP’s consult only adds a redundant stage to care (ie, they send everyone on for a medical consult or review), then they won’t pass that test. From my observation, NPs are much more useful and cost-effective in areas of sub-specialisation (such as wound care, dialysis, some aspects of diabetes) than in generalist areas such as either general practice or emergency medicine. The issue is that a limited scope of practice is not so useful in a a generalist practice.
There is little doubt that this issue is emotive and most doctors have fairly clear and polarised views. I believe nurses are irreplaceable in the healthcare landscape, and I encourage NPs – there is plenty of work to go around. As long as they are prepared to accept the responsibility of their practice, and their patients are as well. I do have issues with the remuneration from the MBS. In a limited funding model, and as a very experienced non-VR doctor, I cannot accept the social engineering of Medicare to value me as equal or even less worthy than a NP. I DO have to accept responsibility with every decision I make.
The ‘why’ is that some nurse administrators were keen on status improvement and saw ‘nurse degrees’ as the way forward. So they looked around and adopted the US way.
Not satisfied with training and encouraging the maintenance of excellence in nursing at the bedside with (*GASP*) the patient, they pushed for nurses to become ‘doctors-on-the-quick-and-quiet’.
As Pete B observed, both parties are being damaged by what is in place now. We can see that, we can stop it.
Clients? In my practice I see patients. And “efficacious” refers to remedies, not healthcare provision. Pedantic semantics? I don’t think so – to collaborate we need to speak the same language. The science and art of diagnostics is central to the practise of medicine, but it has never precluded caring and providing analgaesia and emergency treatment when appropriate.
The thing that worries me, as well as all that’s been said above, is: who is going to look after the patients in hospital and the community who still need actual nursing care? If nurses now want to be de facto doctors where will we find the nurses, who are already in short supply? We still need people to run the wards, bathe and feed patients, administer treatment and sympathy, take observations, dress wounds, lay out the dead, scrub and scout in theatre and the many other demanding clinical roles nurses fulfil with the training they have chosen to undertake. These tasks are an essential part of the health system which needs all health professionals to fill their own roles in a team to provide complete patient care.
To me, one of the saddest things about this whole issue is that both parties are being damaged. We, who should be working together, as one or two pointed out, have been set against each other by the way this has been done and set up. The whole system, AS ENVISAGED – AND NOW A FACT, is so outrageous in it’s present form, we are basically at a loss for words to describe why… so left to splutter and fizzle and make undignified comparisons between relative experience, training and qualifications… because it’s just such a BAD IDEA! Words do fail you to describe exactly why – we just KNOW…….
We don’t want to get into a situation of criticising other health professionals, but I fear we are down this path already. It’s obvious that nurses cannot replace doctors totally in primary health care and if they try then there will be lots of untoward events and probably deaths. I wonder about nursing practitioners who state that NPs can do most of what GPs do. As one of my more learned specialist colleagues said “general practice is the hardest specialty to do well.”
The main point I have is, what is the strategy of the Federal Government in this. If they are not careful they will destroy primary health care delivery and standards. Unfortunately their record (the last 3 years) on implementation of various policies so far has been poor.
As it is, in Australia I note and observe a definite overall decline in clinical standards in recent years, and the apathy of most people in the health system to this is very concerning. I am continually amazed at the unrealistic expectations of many patients, the falling ability of the system to deliver appropriately, and the increasing (still) risk of litigation.
I think clinical doctors – and clinical nurses – need to be put back in charge of hospitals and the health system. There first needs to be a focus on delivering good clinical health care, and then on public health generally.
A Master’s course? Well hooray, that’s fantastic. Only problem is, I learnt ten times as much in my first six months as an intern as I had in six years in medical school.
Flight attendants know a lot about safety, and have prevented many disasters by observing problems, but they don’t end up doing a bridging course and becoming co-pilots. I guess in the cockpit, the staff’s lives are on the line as well so boundaries don’t become blurred so easily.
The NP business is like the rest of public hospital care, few people care enough about quality because the important people either go private or know back-door ways of getting things done in public.
A lot of criticism above of the Nursing Masters, accompanied by the presumption that an MB BS is so much better. I did a ‘self-directed learning’ medical degree (UQ), and didn’t get any formal training in pharmacology, anatomy or anything else much useful. Nurse practitioners tend to apply protocol based solutions to a given problem (sounds like ICU), and while this has flaws, they are obvious and consistent flaws. Unlike the intern in a regional ED with a lifelong interest in chemical pathology being supervised by a CMO from the next room.
Most of the critical comments above could equally be applied to doctors. Maybe it’s time to start listening.
I agree with all the recent posts. Will you see a NP if you fall sick? I have seen alarming diagnostic and management plans by NP candidates. It is sickening to see where we are heading. I have seen how useless these Masters degrees are – run by nurses for nurses on irrelevant topics. This is our path to further and further destruction.
I have enough headaches training NP candidates now! I was supportive on the idea initially. I have seen the products that are coming through now. I do not want to be a part of this destruction any more.
Sorry, there is a fair it of difference between the NP Masters and a medical degree. A close friend did the NP Masters – he couldn’t understand the physiology, pathophysiology or pathology – not because he was dumb, but because the course here is so dumbed down with no emphasis on first principles or the like, true safety issues, etc. He passed with distinction! The level was at the equivalent of the 2nd year of my science degree, not even a the level of first year med.
He has since left primary health after he killed a couple of people – thought he could use an infusion of fluids and potassium (had no clue about fluid shifts and electrolyte balances, correct fluids use). BTW, how can you “inadvertently” give someone an ACE inhibitor, diuretic and NSAID – my second year students know not to give that and to counsel patients to not take the combination (as NSAIDs are available over the counter) – this is how he killed the other. He’s much happier as a drug rep now. I’m all for NPs, but why not have an intern equivalency with limits on prescribing hard core meds until better trained and experienced or concentrate on chronic health managment and advice?
All the above comments have said it all. It is not that doctors don’t welcome collaboration with the nursing fraternity but that some practitioners, like the article writer, are trying to equate the two – they are not the same and very far from it. As one said, if you want to play doctor go get a medical degree.
We all should work together but we do not have to accept your referrals or advice.
NPs have not completed “the same courses as medical colleagues”.
They have not completed a degree in medicine, with highly competitive entry, high standards and a broad base of knowledge needed to pass. Instead they have done nursing degrees which mostly anyone can get into and pass. This is followed up by a Masters, usually from an institution of very dubious merit where no-one fails. I have seen the curriculae of some of these so-called Masters qualifications – laughable.
Nurses are good for chronic disease management, and I support their use solely in that area. For any diagnostic role they are untrained, unsuited and either useless or dangerous.
The only reason they call themselves nurse practitioners is to try and blur their real background. It’s called doublespeak to use language to convey misleading meanings.
Partnerships, collaboration, facilitation. All good things! Thing is though – that happens well when people have complementary roles, not IDENTICAL roles. If you want to be a doctor – there’s a course for that. It’s called an MB BS. Why do a different course and then say I want to do things that doctors do? Medicine’s not so hard these days – 4 years post-grad. It’s been pretty well watered down anyway. Go do that!
So many slogans, so many motherhood statements, but no facts. Lots of marketing tools: The “nursing model ( I am not sure what that is) is represented as “progression” and “evolution” in opposition to the “medical model”. A reliance on the tall poppy syndrome in Australia. The misuse of overseas experience in totally different health care settings. The emphasis on the Masters of NP degree as being academically equivalent to as a medical qualfication, which is just factually inaccurate (speaking from experience, its almost impossible to fail a Masters unless you just do not submit the assignments). So many questions, but not many real answers for the average patient.